Form E-Qtr - Ahcccs Contractor Quarterly Premium Tax Report - Arizona Department Of Insurance - 2013

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AHCCCS CONTRACTOR
I N S U R A N C E T A X U N I T
Arizona Department of Insurance
QUARTERLY PREMIUM TAX REPORT
th
2910 North 44
Street, Suite 210
2013
CALENDAR YEAR ______
Phoenix, Arizona 85018-7269
TC 1
Phone: (602) 364-3997 | Fax: (602) 364-3989
ORIGINAL REPORT
TC 2
SUPPLEMENTAL REPORT
Reset Form
AHCCCS Contractor Complete Name (select from drop-down list)
Federal Employer ID Number
Preparer’s Name
Title
Toll-free/Collect Phone Number
Fax Number
E-mail Address
You must file this report and pay estimated premium taxes on or before each due date shown below.
ARS §§ 36-2905 and 36-2944.01. See Form E-QTR.INSTRUCTION for further assistance.
1. Check the (one) box that corresponds to the quarter for which you are filing this report.
OFFICE USE ONLY
CHECK
DUE DATE FOR TAX
FOR CONTRACTOR CAPITATION IN
ONE
REPORT AND PAYMENT
PAY CODE
PERIOD
QUARTER 1: January 1 through March 31
1
74
March 15
QUARTER 2: April 1 through June 30
4
76
June 15
QUARTER 3: July 1 through September 30
19
78
September 15
QUARTER 4: October 1 through December 31
20
79
December 15
2. Enter the AHCCCS Plan ID Number and the estimated amount of total capitation including reinsurance
and any other reimbursements that the Arizona Health Care Cost Containment System paid you for this
quarter for each plan type.
AHCCCS Plan Type
Plan ID Number
Estimated Amount
Acute Care
AC
Ventilator Dependent
VD
Elderly & Physically Disabled
EPD
0.00
QT
LINE 2 TOTAL
$0.00
3. PREMIUM TAX DUE = 2% X LINE 2 TOTAL amount above
4. CIVIL PENALTY AND INTEREST: If you pay the PREMIUM TAX DUE on Line 3 after the DUE DATE,
complete Lines 4a, 4b, 4c and 4d.
4a
Postmark or OPTins entry date:
Late Payment Penalty: 5% X Line 3 or $25, whichever is
4b
greater
Interest: = 1% X Line 3 for each full/partial month that
4c
your payment is late.
$0.00
TOTAL PENALTY AND INTEREST DUE: Line 4a + Line 4c
4d
26
Complete and attach Page 2 if not $0.00.
5. PRIOR QUARTER ADJUSTMENT
:
$0.00
See Page 2 for details.
$0.00
Contractor #
6. TOTAL PAYMENT DUE: Sum of Lines 3, 4c and 5
You can electronically file tax reports and pay taxes via the NAIC OPTins system. Visit the NAIC
Web site at
or call (816) 783-8990
To pay by check: Make your check payable to Arizona Department of Insurance and mail it with this
form to the address above.
E-QTR (REV. 01/10)
P
1
2
AGE
OF

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